ATI RN
Nursing Care of Children ATI
1. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?
- A. Maternally derived iron stores are depleted in the first 2 months.
- B. Fetal hemoglobin results in a shortened survival of red blood cells.
- C. The production of adult hemoglobin decreases in the first year of life.
- D. Low levels of fetal hemoglobin depress the production of erythropoietin.
Correct answer: B
Rationale: Physiologic anemia is caused by the transition from fetal to adult hemoglobin, with fetal hemoglobin having a shorter lifespan, leading to a temporary decrease in red blood cells.
2. The nurse is preparing to admit a 10-year-old child with appendicitis. What clinical manifestations should the nurse expect to observe?
- A. Fever
- B. Vomiting
- C. Tachycardia
- D. All of the above
Correct answer: D
Rationale: Correct! Typical signs of appendicitis include fever, vomiting, and tachycardia due to infection and inflammation. These clinical manifestations are commonly observed in patients with appendicitis. Hyperactive bowel sounds are not typically associated with appendicitis, so they are not expected findings in this situation. Therefore, the correct answer is 'All of the above.'
3. The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury?
- A. Female, multiple siblings, stable home life
- B. Male, high activity level, stressful home life
- C. Male, even-tempered, history of previous injuries
- D. Female, reacts negatively to new situations, no serious previous injuries
Correct answer: B
Rationale: A male child with a high activity level and a stressful home life has multiple risk factors for childhood injuries, requiring closer supervision and preventive measures.
4. The nurse is providing anticipatory guidance to parents of a 4-month-old infant on preventing an aspiration injury. What should the nurse include in the teaching?
- A. Keep baby powder out of reach.
- B. Inspect toys for removable parts.
- C. Allow the infant to take a bottle to bed.
- D. Teething biscuits can be used for teething discomfort.
Correct answer: A
Rationale: Baby powder can be inhaled by the infant and cause respiratory distress. Toys should be inspected to prevent choking hazards. Allowing an infant to take a bottle to bed can increase the risk of aspiration, and hard foods like teething biscuits should be given with caution.
5. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
- A. Feet and hands
- B. Bridge of nose
- C. Circumoral area
- D. Mucous membranes
Correct answer: A
Rationale: Nonpathologic cyanosis in newborns shortly after birth is typically present in the feet and hands, known as acrocyanosis. This is a normal finding due to the immature peripheral circulation in newborns. Cyanosis of the bridge of the nose, circumoral area, and mucous membranes indicates generalized cyanosis, which suggests a potential underlying distress or major abnormality. Therefore, choice A is correct as it describes the expected location for nonpathologic cyanosis in newborns, while choices B, C, and D represent areas associated with abnormal cyanosis.
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